Intermediate Standardized SALARY SUPPORT/INCENTIVE Payment Scales for Civil servants and Health Workers

Transcription

1 Proposal Paper IV: Intermediate Standardized SALARY SUPPORT/INCENTIVE Payment Scales for Civil servants and Health Workers Somaliland Prepared by: Austen Davis EC Lot3 Health Sector Development Fund Coordinator 1

2 PART 1 Discussion Paper PART 2 Proposal for Intermediate Implementation.13 2A Proposal for Civil Servants Working in Ministries or Governmental Institutions B Medical facility Workers C Teachers/Education facility Workers

3 PART 1 Discussion 1A Introduction/background Health care systems are complex, employing a vast number of employees with varying levels of education, required experience and responsibilities. Hence a differentiated, performance based hierarchical salary system is an important management tool to allow creation and reinforcement of the varied levels in health service delivery and management. Salary systems are necessarily complex so as to meet the requirement to distinguish between persons and differentially reward: o Qualifications o Experience o Position (responsibility both managerial and technical) The authorities of Somaliland have neither the resources nor other capacities to deliver effective and efficient health services to all citizens of Somaliland. Hence the majority of health services are offered through the largely unregulated private market or partnerships between the MoHL and UN/not-for-profit NGOs. The MOHL uses approximately 70% of its overall budget on support of salaries to health workers in the public health service both hospitals and clinics (the rest on transportation and support costs to the Ministry). Not all employees of current operational health facilities are on the official pay-roll. Some health facilities and institutions are supported by NGOs and others not. Otherwise, health facilities and institutions raise finances through charity grants, diaspora contributions, collection of contributions from local business, support from local communities and fees for services and drugs. Health care facilities are frequently under local management and require local financing blurring the distinction between public and private health services and undermining standardization and public health authority. In this context different facilities reimburse their staff in different ways and unpredictably. There is no set of standards and performance based management is consequently extremely difficult even for entirely Somali based institutions (e.g. Hargeisa group Hospital) Health facilities and institutions are often fully staffed or over-staffed but frequently with underqualified staff. The 1300 health care workers on the civil service salary pay-roll include far too few managers, doctors and qualified nurses and too many auxiliaries and unskilled workers. The availability of qualified staff to fill higher positions is low and those in position are frequently not qualified for the job. Without sufficient leadership and middle management the vast numbers of low and unskilled workers are not adequately managed and hence health system outputs are extremely poor (even considering the low levels of investment). For health sector reform to result in improved performance of the public health system the issue of regularization, management and productivity of health workers is one of the key issues and THE most complex issue to address but without progress little advancement can be achieved. 1B. The Problem In a divided and institutionally weak environment, public institutions have neither the resources nor the technical capacity to develop complex and effective rewards system for health care workers (and to implement them). Hence public systems collapse or function perversely and private not-for-profit actors become essential partners in re-establishing some basic functioning. 3

4 One of the major challenges is to define effective reward systems and to ensure they are implemented (i.e. professionals regularly receive sufficient remuneration to keep them effectively engaged in providing public services). In Somaliland there is an official administration with an official budget. The MoHL has a budget of roughly 1 million USD per year (3% of the total official public budget) and over 70% of this budget is committed to salaries for health workers and civil servants. The MoHL claims to support over 1300 staff. But official civil service salaries are: extremely low (frequently below subsistence levels) irregularly paid not all staff are on the payroll differentiation between posts/levels is inadequate (not linked to job descriptions or responsibilities) undermining feasibility of effective management. payment amounts tend to be orders of magnitude below what professionals can obtain on the private market for medical skills. This results in insufficient numbers of skilled professionals, in poorly defined jobs, with incoherent responsibilities, offering part time inputs (as they top up their income through other means) and adds to deeply inefficient and ineffective provision of public health services. In addition, there are large numbers of un(der)skilled staff with questionable contribution to health service delivery on the public wage bill adding to confusion, poor management and low performance output of health systems. Consequently when non-public (international or local NGOs or UN) actors intervene it is an important aspect of their programmes that they negotiate a set of incentives to increase the regularity and absolute levels of compensation of professional and unskilled health service workers and/or to ensure they perform specific core tasks. Box 1 Salaries, Incentives and Stipends/Top-ups A salary is a form of periodic payment from an employer to an employee, which is specified in an employment contract.. A salary is coming to be seen as part of a "total rewards" system which includes variable pay (such as bonuses, incentive pay, and commissions), benefits and perquisites (or perks), and various other tools which help employers link rewards to an employee's measured performance (Wikipedia). And so is an important management tool in defining, structuring and achieving performance in health systems. Incentives are any factor (financial or non-financial) that provides a motive for a particular course of action, or counts as a reason for preferring one choice to the alternatives. Since human beings are purposeful creatures, the study of incentive structures is central to the study of all economic activity (both in terms of individual decision-making and in terms of co-operation and competition within a larger institutional structure). (Wikipedia) Stipends are.. a fixed sum of money paid periodically for services or to defray expenses (Merriam Webster online dictionary). A stipend is a form of payment or salary, such as for an action (?), work experience, food and/ or accommodation. Universities usually refer to money paid to graduate research assistants as a stipend, rather than as wages, to reflect complementary benefits. (Wikipedia) Stipends are generally paid for a fixed short term. Stipends are given to cover costs and provide incentives to do specific tasks (for example to complete a course of study). Incentives are in theory a relatively small top up to a base salary, to direct attention to specific tasks. Nevertheless, where salary levels are unrealistic (low) and salary structures deficient, incentives are often used to compensate. This results in incentive levels many times higher than salaries and incentive structures that compete with the logic behind salary scales. Then the concept of the salary and incentives can become confused. If incentives are relatively high and drive towards specific functions they can undermine commitment to the overall job (as remuneration is insignificant) and disrupt the overall job performance and overall system performance (perverse functioning). 4

5 Incentive levels are often negotiated locally between the NGO and local counter-parts that may have very different motives from each other in why they wish to offer incentives, what are the structures of incentive systems and what they expect in return. The confusion between salaries, stipends and incentives (and locus of responsibility) can be a major bone of contention and tension between external (NGO/UN) providers/employers and staff and between local providers and the public authority. The over incentivization of systems can lead to perverse functioning and system fragmentation. When trying to encourage system reconstruction and overall system productivity it is critical to try and create total reward systems that incorporate realistic salaries and relatively small incentives in order to attract professionals back into the public system; differentiate between levels allowing management and reward people according to performance of their full job responsibilities. Externally driven programmes will tend to continue to incentivize or provide stipends in the absence of strong central leadership providing realistic guidance on: Affordable salary scales in relation to external budgets and longer term projections of state ability to adopt such pay scales. Sufficiently differentiated salary scales to allow formation of an effective management structure to ensure productivity; Salaries linked to standardized job descriptions, With rigorous certification of employees to ensure employees meet requirements of job descriptions; Salary systems/reward packages must be considered in the frame of national civil service conditions and reinforce the authority and responsibility of the Ministry of Health as the principal employer of staff. + On the one hand rewards have to be set high enough to ensure adequate skilled personnel are attracted in to public positions and sufficiently high to allow them to concentrate their efforts into their jobs (implying competition with the private market particularly as skilled health personnel are in such scarce supply). + On the other hand this means top-ups can be set so high that they appear to dwarf official salary scales and to undermine the role of the Ministry of Health as the employer provide perverse incentives for performance - and undermine the long term sustainability of health service delivery (as when donor funds withdraw, the public purse will not be able to sustain the levels of remuneration required to maintain a professional and differentiated workforce and the MoHL will have limited commitment to bodies of staff employed outside their remit). Furthermore, differential salary rates between agencies sets up a never ending discussion with staff and effects motivation and perceptions of justice (absolute amounts as well as differentials between types of employee). Therefore there is a major challenge: (1) For external (NGO/UN) providers to provide staff motivation packages that are realistic and allow them to recruit and keep sufficiently skilled staff to provide effective and efficient services. (2) To coordinate external reward systems with longer term civil service reform (at least to minimize harm). (3) To reduce negative impact of competition between agencies. Given strong and reasonable central leadership on these issues grounded in shared understandings of sustainability and overall civil service reform - it is possible to move sector inputs from uncoordinated short term incentives towards salaries/stipends and full reward packages to incentivize staff to perform their full jobs and to relocate responsibility back to local authorities (as well as to set norms and standards to reduce transaction costs (constant negotiation), reduce tension (fair transparent endorsed norms and standards are applied) and bring authorities into support of partner payment activities). 5

6 1C. Setting Intermediate Realistic Salary Levels. 1C.1 Cost of Subsistence Cost of living analysis by the FSAU has indicated that a minimum nutritional food basket costs roughly 25 USD per month (for a family). The basket does not include any meat or luxury food items and is aimed at what it would cost to sustain a poor household nutritionally (FSAU 2007) IF the family understood exactly what commodities to buy in what proportion to maximize nutritional value for money. The basket does not contain non food items such as housing, clothing, education, transport etc. Research by an NGO in the South has indicated costs of living including education and housing costs would be nearer 100USD per month. The costs of living have been increasing rapidly in the past few months and will impact on all salary level recommendations. The cost of living is variable by region and by season but if anything is more expensive in the North. Hence public salaries for nurses (4 years professional training) etc. of roughly 40USD and doctors of roughly 60 USD per month are obviously below subsistence levels and cannot generate effective commitment by employees to the public system. Unskilled workers cannot survive on these official salary rates and skilled workers must earn extra money to guarantee a minimal standard of living. 1C.2 Daily Wage Analysis for Day Labourers Wages for daily labourers vary, reflecting different local market conditions in terms of supply and demand. Daily rates tend to be higher in the North than in crisis affected south. Table 1. Daily wages are variable over the country (source FSAU 2008): Location Rough wage (USD) Burao 2.5 Hargeisa 3.2 The daily wage rates indicate casual labourers need to work 10 days per month just to meet minimal food needs of families (if they purchase nutritionally) AND then must find extra days of work to meet other needs. Assuming 24 day working months in Somaliland; a casual labourer able to get 24 days work would earn USD per month (with variance depending on the area). Again this analysis tends to point to the inefficiency of paying qualified nurses 40USD per month if one expects full service. 1C.3 Salary Scales in Credible Somaliland Private Medical Institutions. Private medical institutions must generate an effective profit (even if they have some nonprofit/societal motives) they must provide the best mix of service for cost they can. This means a private service should seek to find good professional staff and seek to pay them competitively and offer quality services for which there is a high demand. Some renowned private medical institutions (Hargeisa based) with excellent reputation pay the following salary levels: 6

7 Table 2. Salary Scales in Credible Private Medical Institutions Function Facility A (USD (2006) Facility B (USD (2008) Full time regional $ (+accommodation, $2000 expat doctor food and flights) Full time regional $800 (+accommodation, food and expat matron flights) This facility lacks technical leadership and management and does not have this level as yet. Local Doctor $800 * Nurse (local qualified) $150 - $210 $150 $250 Nurse tutor (local $200 - $250 qualified) Midwife $200 - $250 $150 $250 Auxiliary $60 $100 Cleaner $30 - $35 $50 - $80 Accountant ** $400 $200 Administrator ** $200 - $300 Driver $120 - $170 $150 Guard $50 - $55 $50 - $80 * Specialist surgeons are paid on a fee per intervention basis (paid by family to the hospital and the MD reimbursed at end of month according to number of interventions). Exemption costs born by the hospital ** The major variation in rates between the classes and different institutions probably reflects the great differences in job descriptions responsibilities and levels. 1C.4 Initial Research on NGO Incentives Data on incentive systems paid by different NGOs was collected by the EC and DFID. UNICEF collected a number of other salary scales to compliment this work. Findings from an initial comparison of incentive systems indicated: (1) Incentive systems are very different in the central South and in Somaliland reflecting the relative peace and order in Somaliland. (2) Somaliland has a proposed civil service salary system but cannot implement it due to restrictions in the available budgetary resources and inadequate professionalization of the civil service. (3) All professional health staff are officially civil servants. (4) There are a range of other institutions especially medical training institutions where employees are officially on the state payroll and receive salaries according to civil service payment practices. (5) Gaps between private market salary opportunities and current public wages (and even proposed wages) are substantial. This implies professional health staff would only dedicate some of their time or energy to public positions and will operate private practice. (6) Workers in the public health system have access to extra income through other means than official salaries DSA paid for training and workshops by the UN and NGOs, fees for service, private practice, sale of pharmaceuticals, contributions from RHBs, private business etc. If these non-regularized and unpredictable sources of income were withdrawn either the public system as it is would cease to function (too many people paid too small amounts to do anything) OR the Ministries would have to reduce the employment roster and hire fewer staff to provide services through limited facilities. The former is the most likely scenario though not the preferred one. (7) There are few standard job descriptions and most staff is not certified so it is hard to compare across programmes differences in top up levels may represent differences in quality or responsibilities. (8) There does not appear to be a logical hierarchical salary scale with senior persons paid more. Rather top up scales frequently reward technicians more highly than 7

8 administrators, managers and leaders. Top ups reflect the highly localized market who is required for the programme, who is available and what is their worth to the private market. (9) Top up systems vary in their differences between high and low salaries and the civil service scales reflecting local pressure (inflate salaries for higher cadres). (10) DSAs and travel allowances vary but all follow similar logics and could be standardized if felt useful. (11) It was more difficult to get information on top ups paid to MoH staff (central and regional) as well as para-statal staff (mainly UN) (12) There is a booming private medical market public salaries cannot compete with the market hence public salary reform must be linked to broader conditions of service and civil service reform. 1C.5 Intermediate Incentives for Core Functions. All NGOs provide remuneration to workers in facilities (SRCS, COOPi, SC-UK, WVI). The lack of certified staff, standard job descriptions and performance management make it difficult to develop a standard set of incentives. Nevertheless, for a core set of medical staff functions, incentives paid were not vastly different. The first conclusion was to differentiate PHC from hospital staff the second conclusion was to focus on a core set of functions: 3.6 Core Functions: Hospital (USD) Table 3 Incentives paid in NGO supported public hospitals Core Function Agreed Agency levels contribution Hospital Director Hospital Doctor Medical Officer 275 Matron Head Nurse 120 Nurse/Mid Wife 110 Auxiliary Nurse 90 Lab Technician 120 Lab Assistant Hospital Administrator Accountant/ secretary Pharmacist Support Staff 65 8

9 1C.7 Core Functions: Primary Health Facilities (USD) Table 4 Incentives paid in NGO supported MCHs and Health Posts Core Agency a Agency b Function Head Nurse 120 Nurse/Midwife 100 Outreach Nurse Auxiliary 120 Mid-wife Auxiliary HP auxiliary It would seem possible to define standard job descriptions for a core set of MCH and HP staff and to set fixed base incentive levels. The standard salary rates should be tied to civil service salary scales. 1D. National Civil Service Proposals In 2005 The National Civil Service Commission made a study of civil service remuneration packages. They recommended a temporary scale, according to current budgetary constraints and a proposed scale for future implementation. The proposed scale allowed for more grades and levels within grades to increase the range of differentiation between posts (management tool) as well as a major increase in salaries. The proposed scale also suggested increments very2 years so salaries row with experience on the job. The NCSC proposed civil service salary levels have never been implemented due to constraints in the budget. Nevertheless, external salary support needs to be linked to officially proposed salary scales and up-graded in view of the discussion above: 9

10 Table 5 NCSC Recommended Salary Levels - Somaliland Grades 2008 Recommended Salaries NCSC A1 1,543, A2 1,403, A3 1,275, A4 1,150, A5 1,054, A6 958, A7 871, A8 792, A9 720, B6 958, B7 871, B8 792, B9 720, B10 650, C7 871, C8 792, C9 720, C10 650, C11 570, D12 390, D13 355, D14 323, D15 294, Exchange rate 6,000 SLsh per USD Recommended salaries NCSC (USD) The table above looks at recommended salary scales under current constraints which has not been realized due to budgetary problems. A major problem in the proposed rates is the high degree of overlap between the different levels so that A6=B6 etc). In order to bring these rates to levels that are at least, under current conditions 1, reasonable according to the market and attract and maintain a professional workforce in full time employment it will be important to recognize the high demand for skilled labour and hence the relatively higher rates that can be commanded by higher skilled cadres in the current workplace. Given the high degree of overlap between grades A, B, C and D which do not allow sufficient differentiation between different professional cadres - as well as the higher levels of pay commanded by those with professional skills in the market (and low levels for the unskilled due to 1 The current state of affairs in Somaliland (with significant levels of instability and civil strife in Sool and Sanaaq) imply the state is not functioning as normal. It is reasonable to assume that if Somaliland reached greater levels of stability as part or separate from a stable Somalia, the economy would improve and increasingly be regulated. The numbers and levels of professional staff available would increase and competition for trained staff and hence salaries might decline. 10

11 high levels of unemployment) we recommend a temporary re-adjustment of the NCSC suggested salary levels. This is to ensure REALISTIC, COMPETITIVE, DIFFERENTIATED total wage levels. The recommendation is to multiply the recommended official scales by A= x3 B= x2.0 C= x1.5 D= x1.25 (to reflect current studies on costs of living and reasonable expectations for long term macroeconomic state budgets as well as competitive packages in relation to the market). The multiplication factors differ by levels to counter-act the huge overlap between grades A D which undermine the utility of grading tools for setting up management systems as well as to reflect current market realities regarding demand for skilled and unskilled labour in the market place. Unfortunately there are a lot of irregularities 1) The different levels are not used within the grades 2) Most personnel do not hold the qualifications required for their jobs and performance is not managed so salaries not tied to conditions of performance by the employee. Salaries should be down graded for those not qualified by paying them according to the grade they are qualified to hold. Salaries should be downgraded proportionally to the hours worked against the standard 42 hour working week. Practical ways should be found to use the full range of grades and scales within grades so as to differentiate between posts and levels of responsibility. Incentives should be used to reward exceptional performance but overall incentive packages should be relatively small compared to salary baselines. The proposed scales are in line with levels of pay commensurate with attracting professional staff to full time posts. The proposed scales are an intermediate step in terms of harmonizing pay rewards for public service staff. Ultimately, there needs to be full a review of the total rewards package in the context of overall civil service reform. The official scales do not reflect managerial responsibility (medical directors etc. It is recommend total remuneration be 20% higher than the appropriate scale for leaders (so for example a medical director would get the scale of a medical doctor *120/100). 1E. Proposal for Action This paper presents a proposal for intermediate reform of salary support to: civil servants in central ministries (MoHL), regional administrations, public institutions (e.g. training institutions) and health facilities (anyone who is eligible to be paid a public wage according to civil service regulations). The job should be rewarded according to a standard salary rate International agencies should move towards standardized salary top-ups over uncoordinated DSAs and incentives. The proposed scales are in line with levels of pay commensurate with attracting professional staff to full time posts. Top ups should be calculated according to what is already paid (total salary salary already paid). 11

12 Incentives can be used to reward specific performances but should not exceed 20% of the salary level and should require additional inputs above and beyond full job performance (not replacement of working hours). This paper proposes a logic behind calculating salary top-ups and calculates suggested levels for Proposed salary top ups need to be recalculated annually to reflect (1) changes in base salaries paid by the government, (2) inflation and changes in the cost of living. This paper proposes these rates be discussed and endorsed by central ministries of health and used as a guideline in negotiation with partners. This paper does not propose these new guidelines be implemented overnight and will need to take into account funding cycles (NGOs may have to apply for new funds or wait until the next funding cycle to rearrange budgets for funding of civil servants). Rather if the MoHL, NCSC/government, UN agencies and donors all agree on this proposal, it establishes a path to move towards regularization, restructuring and management for performance of the public health system in lieu of implementation of broader proposed civil service reform (critical in the longer term). Proposed salaries are for full time employment of qualified staff this proposal should be urgently followed up with definition of a core list of standard jobs. New appointments should be made with focus on attracting qualified persons to the job. Payment should be on the basis of the proportion of professional time dedicated to the remunerated position (i.e. 2 days work per week in the public system -> 1/3 rd of the proposed salary). 12

13 PART 2 Proposal for Intermediate Implementation 2A Proposal for Civil Servants Working in Ministries or Governmental Institutions All civil servants targeted for support should be supported in the form of salary top-ups. Members of Ministries paid as consultants or given incentives for specific tasks should be phased out. Salary top-ups should be realistic enough to attract quality workers into the public sector but not unrealistically high. Support should be given to civil servants to fulfill their total responsibilities. Salary support should be given with strict conditions for performance (adhering to civil service codes and work times). Staff are paid for full time employment which is a 42 hour working week. If working hours are less or productivity is unsatisfactory part or all of the salary support should be with-held (proportionally). Staff to be supported should be managed by those to whom they are accountable in the government bureaucracy management reports should be provided to the support agency and performance evaluations verified before salary support is transferred. Staff to be supported should continue to receive their government wages if not then salary support should not be forthcoming. If the person s qualifications do not match the job responsibilities they should be graded according to their qualifications and receive lower levels of salary support. All staff to be supported should be graded according to standard civil service criteria by the NCSC salary support should be proportional to NCSC recommendations and policies. Incentives should make up a relatively small proportion of overall remuneration (<15%). 13

14 SUGGESTED FULL TIME SALARIES Grades 2008 Recommended Salaries NCSC 2008 Recommended salaries NCSC (USD) 2008 Recommended Salaries NCSC *3 A1 1,543, A2 1,403, A3 1,275, A4 1,150, A5 1,054, A6 958, A7 871, A8 792, A9 720, Recommended Salaries NCSC *2.0 B6 958, B7 871, B8 792, B9 720, B10 650, Recommended Salaries NCSC *1.5 C7 871, C8 792, C9 720, C10 650, C11 570, Recommended Salaries NCSC *1.25 D12 390, D13 355, D14 323, D15 294, Exchange rate 6,000 SLsh per USD. The top ups provided by international donors should be according to the above recommended salaries and taking into account current salary payments from the government which must be continued as a condition of salary support. 14

15 Salary Support or Top Up Levels Scales 2007 Actual 2007 USD Proposed Total Salaries Salary (NCSC * x) Top Up at today salary A1 (DG) , = 1,023,800 A2 (Head 423, , Dept.) = 623,800 A3 423, A4 423, A5 423, A6 423, A7 423, A8 423, A9 423, B6 345, B7 345, B8 345, B9 345, B10 345, C7 266, C8 266, C9 266, C10 266, C11 266, D12 156, D13 156, D14 156, D15 156, * exchange rate used 6,000 SL shillings/usd Annual Re-Evaluation Total salaries (and therefore top-ups) need to be upgraded every 2 years on the job by a factor of 5% to reflect experience and seniority (capped after 10 years or 5 up-grades). Total salaries (and therefore top-ups) need to be upgraded every year to reflect inflationary pressure (based on FSAU market data) to be calculated at end December of each year. DSA and meeting attendance rates need to be down-graded or even eradicated as staff are now paid and part of their job responsibilities are to attend important meetings. 15

16 2B Medical Facility Workers Hospitals The proposal for hospital staff is to support generic medical professional cadres and unskilled or semi-skilled non-medical functions. The salary levels do not including allowances for skilled diaspora, housing/hardship allowances, training, workloads. These need to be worked out in the context of longer term recommendations to the staffing of the public health system (intermediate solutions may need to be agreed upon to ensure staffing of isolated facilities or hardship facilities). They should be agreed upon between all agencies in a region through regional coordination mechanisms and supported by local authorities. The grades reflect total remuneration levels, so if the MOHL or the community pays some of the fee, then the NGO should only make up the difference to ensure the total remuneration level is met. If the employee does not work full time then the rates should not be provided in full. Grades are for a 42 hour working week. Hospitals must run on a shift basis offering roundthe-clock professional care. If staff work more or less than the 42 hours their salaries should be discounted according to the hourly rates indicated in table 7. 16

17 Table 7. Recommendations for remuneration of Somaliland Hospital Staff Grade Basic function Basic Salary Over-Time Hourly Rate A1 Hospital Director (MD) $775 $4.25 A2 Senior Consultant - $700 $4.00 Specialist A3 Senior MD head of $640 $3.50 ward (with 2+ MDs and 4+ nurses under supervision) A6 Junior MD $480 $2.75 A7 Hospital Manager $435 $2.50 (university degree/mba) B6 Clinical Officer* $320 $2.00 B7 Matron Tutor $290 B8 $265 B9 Senior Nurse $240 $1.50 B10 Nurse-Midwife Pharmacist $215 Lab Tech C11 Auxillary nurse Aux Mid-Wife Aux Pharmacist Aux Lab Tech (certified) $145 $0.85 D12 Driver $80 $0.45 Electrician D14 Guards $65 $0.40 D15 Cleaner Cook $60 $0.35 * A clinical officer is considered here to be a medically qualified nurse or midwife with 2 years post basic training able to perform diagnostic and curative interventions to a reasonably high level. The CO may be trained and used for specific functions in a hospital setting (anaesthesia, caesarians), or may serve in a more general function in a health centre as a senior medical professional in lieu of a medical doctor. This cadre currently does not exist or is not well defined. 17

18 Primary Health Care Facility Staff Table 8. Recommendations for Remuneration of Somaliland PHC Staff Base Salary Qualified nurse or $215 mid-wife Auxiliary nurse/ midwife $145 Auxiliary/CHW $80 Non-skilled staff $60-65 No additional factors required to be factored in 2C TEACHERS/EDUCATION FACILITY WORKERS Grade Staff Salary Level 18